“I Paid for Critical Illness Insurance, But They Are Refusing to Pay”: Dealing With The Reality of a Denied Critical Illness Claim

Imagine this: you’ve been paying premiums for years, believing that your critical illness insurance policy will protect you if you ever face a life-altering diagnosis like cancer or kidney failure. Then, the unthinkable happens—you’re diagnosed with a major illness, and you’re relieved that your critical illness insurance will finally provide the financial support you need. But instead of receiving the lump sum payment to help cover medical expenses, you’re met with a denial letter from your insurance company. “I paid for critical illness insurance, but they are refusing to pay,” is a phrase far too many Canadians find themselves saying in their time of need.

This is a frustrating, often overwhelming experience. After all, you’ve been paying into this policy, expecting that it will be there when you need it most. Unfortunately, critical illness insurance claims can be complicated, and many claims are denied for reasons that might not seem fair. Let’s break down what critical illness insurance covers, why claims are denied, and how DWA Law can help you fight for your legal rights.

Critical illness insurance policies generally provide a one-time, tax-free lump sum if you are diagnosed with a serious medical condition covered by your policy. The goal of this coverage is to help you manage the financial fallout of a critical illness. 

Critical Illness coverage can vary, however, covered conditions typically include cancer, heart attack, stroke, kidney failure, multiple sclerosis, and Lou Gehrig’s disease (ALS), among others. Some policies also cover organ transplants or conditions like blindness or deafness. These policies are not the same as a life insurance policy or long-term disability insurance. They’re specifically designed to provide financial support upon the diagnosis of certain critical illnesses.

However, the details vary widely depending on the specific critical illness insurance policy you have. Not every illness is covered, and there are often strict guidelines on what qualifies. For example, the policy may cover only specific types of cancer or exclude conditions that are considered “less severe.”

There are a few common reasons why an insurance company might refuse to pay out on a critical illness insurance claim:

1. Pre-Existing Conditions: Many claims are denied based on undisclosed pre-existing conditions. Insurance companies often comb through your medical history to find anything that could have contributed to your illness. Even if the pre-existing condition is unrelated to the critical illness for which you’re claiming benefits, this could be grounds for a denial.
2. Material Misrepresentation: Insurers can deny a claim if they believe the policyholder failed to disclose relevant information when they applied for the policy. This is called “material misrepresentation.” Even innocent omissions or misunderstandings can lead to claims being denied.
3. Non-Disclosure: Similar to material misrepresentation, failing to disclose key facts, such as your family history of certain illnesses, can be used as a reason for denial. Insurers argue that had they known the full details of your medical background, they might have either refused coverage or increased your premiums.
4. Policy Exclusions: Insurance policies often have exclusions that are buried in the fine print. These exclusions can include time limits (like a survival period where the insured person must survive a certain number of days post-diagnosis before they can file a claim) or the requirement that your condition meet the insurer’s strict medical definitions.
5. Definition Disputes: Another common tactic used by insurers is to dispute whether your diagnosis meets their specific criteria. 

When you or a loved one is battling cancer or recovering from a stroke, the last thing you need is to be embroiled in a dispute with an insurance company. With medical bills piling up, mortgage payments looming, and income reduced, the stress can become unbearable.

But here’s the reality: insurance companies are businesses. They aim to maximize profits, and unfortunately, that often means denying or delaying claims, even when those claims are valid. Many people give up at this stage, assuming they have no options left. But that’s where DWA Law’s critical illness lawyers can help.

If your critical illness insurance claim is denied, the first step is to carefully read the denial letter and understand the reason behind the decision. Was it based on a pre-existing condition? Non-disclosure? Definition disputes? Knowing exactly why the claim was denied will help you and your critical illness insurance lawyer figure out the best course of action.

Many insurance providers have an internal appeals process. This is where you can gather additional medical evidence, clarify misunderstandings, and provide documentation to support your claim. It’s essential to act quickly, as there are often strict time limits for filing an appeal.

If your appeal is unsuccessful or if you’re struggling to make sense of the claims process, it’s time to consult a life and critical illness insurance lawyer. At DWA Law, we understand the ins and outs of critical illness policies, and we know the tactics insurers use to avoid paying claims. With experienced lawyers by your side, you can challenge the denial and fight for the benefits you’re entitled to.

At DWA Law, we help clients with critical illness insurance claims that have been denied. 

We know how to communicate with insurance providers, challenge their findings, and present compelling medical evidence to support your claim. We’ll guide you through the process of appealing a denied claim, and if necessary, take legal action on your behalf. Our goal is to relieve the burden on you, so you can focus on what matters most—your health and recovery.

Our services extend beyond just critical illness claims. We help those who are dealing with the aftermath of medical malpractice. Proving malpractice requires in-depth knowledge of both medical standards and the law, and we are equipped to handle complex cases involving surgical errors, misdiagnoses, and other failures in medical care. A medical malpractice lawyer from our team will meticulously review your situation, collaborate with medical professionals, and build a strong case to hold healthcare providers accountable for their mistakes. Whether it’s recovering compensation for long-term care, lost wages, or ongoing medical expenses, we’re committed to seeking justice on your behalf.

At DWA Law, our ultimate goal is to relieve the legal burden so you can focus on what truly matters—your health and recovery. 

Remember, you don’t have to go through this alone. If your critical illness insurance claim has been denied, contact DWA Law. Our experienced team of personal injury lawyers will fight for your legal rights.